GMPPA defects cause a neuromuscular disorder with α-dystroglycan hyperglycosylation.

GDP-mannose-pyrophosphorylase-B (GMPPB) facilitates the generation of GDP-mannose, a sugar donor required for glycosylation. GMPPB defects cause muscle disease due to hypoglycosylation of α-dystroglycan (α-DG). Alpha-DG is part of a protein complex, which links the extracellular matrix with the cytoskeleton thus stabilizing myofibers. Mutations of the catalytically inactive homolog GMPPA cause AAMR syndrome, which is characterized by achalasia, alacrima, mental retardation, and muscle weakness. Here we show that Gmppa KO mice recapitulate cognitive and motor deficits. As structural correlates we found cortical layering defects, progressive neuron loss, and myopathic alterations. Increased GDP-mannose levels in skeletal muscle and in vitro assays identify GMPPA as an allosteric feedback inhibitor of GMPPB. Thus, its disruption enhances mannose incorporation into glycoproteins including α-Dg in mice and men. This increases α-Dg turnover and thereby lowers α-Dg abundance. In mice dietary mannose restriction beginning after weaning corrects α-DG hyperglycosylation and abundance, normalizes skeletal muscle morphology, and prevents neuron degeneration and the development of motor deficits. Cortical layering and cognitive performance, however, are not improved. We thus identify GMPPA defects as the first congenital disorder of glycosylation characterized by α-DG hyperglycosylation, unravel underlying disease mechanisms and point to potential dietary treatment options.